fistulized chronic and complex anterior perinea
Presented by Dr Louis-Franck Télémaque, MD
Mr X Seen for complaint of pain, mass and passage of pus near the anus.
The patient is 38 years old, measure 1.82 m, weigh 180 lbs. Vital signs are within normal limits. But the patient complains of perineal pain, rated at 6 on a scale of 1 to 10. He suffered from several episodes of perinea abscess for 5 years. The current illness goes back a week, having started with a febrile syndrome followed by intense perineal pain, of painful para-anal tumefaction, syndrome which was only resolved after spontaneous rupture of the abscess and abundant passage of purulent material.
He suffered from parasitosis and gastroenteritis during his youth and his parents are hypertensive and diabetic.
The clinic examination is within normal limits, except at the level of the perinea, where we noticed a left para-anal zone presenting an increased of volume centered by a granulomatous and hyperemiated slough at two o’clock by which fate material comes out. A fistula scar is noted in the anus at 5 o’clock. At the rectal touch the anal canal is painful. We feel a carton of all the left half of the anal canal. The finger feels an induration at one o’clock at 2-2 cm of the anal margin.
Fig 1: Fistulography of an anal fistula, anorectal path in anterior view. Fig 2: Fistulography of an anal fistula, profil view.
Fig 3: MRI of the small basin to the canal level, and low rectum without particularity.
The diagnostic of probable fistulized chronic and complex anterior perineal abscess was made.
The traitment consisted in the administration of Clavulin (amoxicillin-clavulanic acid, tablet 625mg, two tablets per day during 7 day), Parafortant (tablets 500mg, 2per 24 hr), and the recommendation of hygieno dietetic measures.
The biology is peculiar, except a test HP1 positive. The white blood cells are at 4.500 and the HIV test, negative.
At the rectoscopy, an anterior internal hole is identified at one o’clock as well as a redness of the surrounding anus and rectal wall. We find no other anomalies until the low sigmoid. The imagery available in Haiti consists in obtaining a fistulography and a MRI with opacification.
The fistulography shows the presence of a fistulous path with a slightly uneven outline of about 0.5 cm in diameter over 2 cm followed by a filiform path of 6 cm leading to the opacification of the rectum.[fig.1 and 2]
2- The MRI of the pelvis is without evidence of detectable pathology. [fig.3]
The final diagnosis is that of anterior cryptogenic anterior anal fistula, type 4 of the classification of Alan Packs.
It would exist:
1- A trans-sphincteric path, that starts through a cryptogenic anal orifice (identified with digital rectal examination and rectoscopy and leading to the skin. The initial part (2cm) of the fistulography could lead to the inter sphincterial pocket of the abcedation without opacification of the communication with the anal canal (lack of injection pressure or obstruction of the duct) [fig.1]
2- An extra sphincteric path, beginning from the skin, with or without a communication with the transphincteric path, and leading at the middle part of the rectum. [fig.2]
Proposed treatment in Haiti
The treatment proposed in Haiti would be surgical, under a spinal anesthesia composed of:
1- Tracing of the fistulous by opacification with methylene blue.
2- Fistulectomy of the paths since the external opening until the striated sphincter, with flattening abceded cavities
3- Transphincteric fistulotomy for the low path.
4- Placement of a seton in the extrasphincteric path for gradual lowering.
Choose the best answer
a) The two useful exam are endoanal ultrasound exam and the MRI of the anal canal and the pelvis.
b) It is not important to specify the main path, the collections, and accessories path.
c) Preexisting sphincteric lesions Don’t represent a risk factor of anal incontinence.
d) These exams are not desirable in emergency.
e) Bacteriologic exams are not needed.
About the risk cofactor of the anal incontinence:
a) Preexisting perineal traumatism.
b) Sphincter deficiency
c) Multi operated patient
d) Atypical fistula of specific infectious origin (tuberculosis, actinomycosis or gonococci)
e) All the answer are true
About the surgical treatment
a) The results are independant to the experiences of the surgeon.
b) Fistulotomies techniques in one step for low fistulas and in several steps for the high fistulas give good results with low rate of recidive rate.
c) A rare complication is the anal incontinence.
d) To improve the healing rate,the selection of patients is not imperative.
e) Any attempt at repair don’t wait for the control of the septicemia.
About the new non surgical techniques (NCT)
a) The NCT have as commune objective to diminish the anal sphincter lesions and to optimize the functional results.
b) The NCT will become an alternative to fistulotomy in case of high transphincteric fistula.
c) The NCT, the most promising are: the endorectal advancement flap, fibrin glues, the anal fistula plug.
d) The technic of the future are: the closing of the internal orifice of the fistula without touching the path. The intersphincteric ligature of the fistula, the developed adipose stains cells, fistula treatment by video on-going support. The radial emission laser probe.
e) All the answers are true.
About the prognostic of NCT
a) The risk of anal sphincter lesion and subsequent malfunction is almost zero, it is also the case for chronic recurrent fistula.
b) Sphincterian saving techniques has a risk of increased recurrence.
c) The NCT improve the prognostic of the women with anterior fistula or who already have an obstetrical lesion.
d) The NCT promote the healing of patients with a preexisting incontinence or specific risk (anterior local irradiation or a coexisting Crohn disease).
e) In the case of a specific risk, a flap for endorectal advancement is not a more alternative on.
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Date de dernière mise à jour : 11/07/2021